Multiple Choice Questions

Upper Limb Pathology

Test your knowledge , learn more and get ready for your orthopaedic exam

 51. What muscles will lose power due to the with stab injury to the median nerve in proximal forearm?

A) Flexor pollicis longus and abductor pollicis longus
B) First two lumbricals and abductor pollicis brevis
C) Flexor digitorum profundus and flexor carpi ulnaris
D) Flexor digitorum superficialis and first two palmar interossei
E) First two dorsal and palmar interossei

Correct Answer :B

In the cubital fossa, the median nerve supplies pronator teres, palmaris longus, FCR, FDS. Occasionally PT is supplied above the elbow. In the forearm it gives off the anterior interosseous nerve which supplies FPL, PQ and usually the radial half of FDP (index and middle). In the hand the median nerve gives off the recurrent motor branch supplying APB, FPB and opponens pollicis muscles. The palmar digital branches supply the two radial lumbricals.

Author : Firas Arnaout

 50. With regards to Wartenberg’s Syndrome, which one of the following statements is true?

A) Typically associated with weakness of wrist dorsiflexion
B) Paraesthesiae along the dorso-radial side of the hand
C) Pain along the ulnar side of forearm
D) Aggravated by forearm supination
E) Surgery is usually required

Correct Answer :B

Wartenberg’s syndrome is caused by compression of the superficial sensory branch of the radial nerve between the tendons of brachioradialis and extensor carpi radialis longus with forearm pronation. Symptoms include pain, numbness and paraesthesia over the dorsoradial aspect of the hand. Provocative tests include forceful forearm pronation for 60 seconds and a Tinel sign over the nerve.

Author : Firas Arnaout

 49. Care should be taken to avoid the dorsal sensory branch of the ulnar nerve while performing ulnar shortening osteotomy. Please select the direction of this nerve while crossing the wrist joint from the following options:

A) From volar to dorsal just distal to the ulnar styloid, at an angle of 45° to the long axis of the forearm
B) From dorsal to volar just proximal to the ulnar styloid, at an angle of 45° to the long axis of the forearm
C) From volar to dorsal just distal to the radial styloid, at an angle of 45° to the long axis of the forearm
D) From dorsal to volar just distal to the ulnar styloid, at an angle of 45° to the long axis of the forearm
E) From volar to dorsal just proximal to the ulnar styloid, at an angle of 45° to the long axis of the forearm

Correct Answer :A

The sensory branch originates on average 5 cm proximal to the ulnar styloid process and 2 cm radial to the subcutaneous border of the ulna. The nerve crossed the subcutaneous border of the ulnar from volar to dorsal on average 0.2 + 1.1 cm proximal to the ulnar styloid process

Author : Firas Arnaout

 48. What shoulder examination is a test for impingement?

A) Crank test
B) Hawkins’ test
C) O’Brien’s test
D) Rubber band sign
E) Speed’s test

Correct Answer : B

Hawkins’ test is passive forward flexion and internal rotation. If there is pain at 90 degrees then there is possible acromion impingement. If pain at 120 degrees then there is possible acromioclavicular joint (ACJ) joint impingement.

Speed’s test is used to examine the proximal tendon of the long head of the biceps. Forward flex the shoulder (60 degrees) against resistance while maintaining the elbow in extension and the forearm in supination – tenderness in the bicipital groove indicates bicipital tendinitis.

O’Brien’s test is the shoulder held in 90 degrees of forward flexion, 30 to 45 degrees of horizontal adduction and maximal internal rotation. Grab the patient’s wrist and resist the patient’s attempt to horizontally adduct and forward flex the shoulder.

Rubber band sign is resisted maximal external rotation. Pain is experienced in infraspinatus lesion.

Crank test – full abduction, humeral loading and rotation. Pain is experienced in SLAP lesion.

Author : Firas Arnaout

 

47. With regards to the ‘Painful Arc Syndrome’, which of the following statements is true:

A) Tenderness is generalised
B) Typically there is severe pain on intiating abduction
C) The cause is a tear of the supraspinatus tendon
D) If untreated, a ‘frozen shoulder’ often results
E) Calcification in the region of the Supraspinatus tendon is not seen on X-ray radiographs

Correct Answer : D

If the pt is inhibited in the movement of the shoulder due to pain then the capsule contracts and a frozen shoulder ensues. Other statements are False b/c: Tenderness is usually localised to rotator cuff muscles. Pain is typically on adduction. Tear of Supraspinatus is NOT seen in painful arc syndrome (it rather involves inflammation of Supra Tendon) , but in a rotator cuff tear (different condition). Calcification in the region of Supraspinatus may be seen on X ray since the Syndrome is caused by the inflammation of the same tendon.

Author : Liam Borg

 

46. Which is true of the shoulder joint?

A) Supraspinatus is active in abduction
B)The nerve to serratus anterior is derived from the lower roots of the brachial plexus
C) The rotator cuff muscles are attached to the capsule which is deficient anteriorly
D) The subacromial bursa communicates with the shoulder joint
E) She subscapular nerve arises from the lateral cord of the brachial plexus

 

45. Which one of the following is NOT a recognised complication of Colles’ Fracture

A) Loss of Palmar Flexion
B) Sudek’s Atrophy
C) Median Nerve Compression
D) Loss of full Supination
E) Avascular necrosis (AVN) of the Lunate bone

Correct Answer : E

 AVN of Lunate is NOT a complication of Colles’ fracture, and occurs spontaneously with unknown aetiology. Other Statements are correct. Palmar flexion might be initially lost prior to reduction due to the dorsal displacement of the wrist joint and hence limited arc of motion. Sudek’s atrophy is a rare but a recognised complication of Colles fracture (presenting with a pain, stiffness + swelling, sweaty, cold wrist. Median nerve Compression might occur due to a haematoma compressing it at the carpal tunnel. Loss of Supination is a potential complication of the distal radial fracture, esp in cases of malunion since the fragment prevents the distal radioulnar joint from supinating fully due to bony fragment.

Author : Liam Borg

 

44. Which one of the following is NOT a recognised cause of Carpal Tunnel Syndrome (CTS):

A) Fractured of Distal Radius
B) Fractured Scaphoid
C) Pregnancy
D) Dislocated Lunate
E) Rheumatoid Arthritis

Correct Answer : B

Other options are known causes of CTS, Distal radius fracture can cause median nerve compression through bleeding into the carpal tunnel; Pregnancy causes fluid retention with subsequent CTS; Lunate bone dislocation anteriorly causes direct compression of median nerve; Synovial hypertrophy in RA causes CTS.

Author : Liam Borg

 

43. Which of the following correctly pairs the anatomical space of the shoulder with its contents?

A) Quadrangular space; radial nerve and profunda brachii artery
B) Quadrangular space; axillary nerve and scapular circumflex artery
C) Quadrangular space; axillary nerve and posterior humeral circumflex artery
D) Triangular space; axillary nerve and posterior humeral circumflex artery
E) Triangular space; radial nerve and profunda brachii artery

Correct Answer : C

The quadrangular (quadrilateral) space of the shoulder contains the axillary nerve and posterior humeral circumflex artery.
The shoulder contains three anatomically importance spaces: the quadrangular (quadrilateral) space, the triangular space, and the triangular interval. 

The quadrangular space contains the axillary nerve and posterior humeral circumflex artery, and is bordered by the long head of the triceps medially, humeral shaft laterally, teres minor superiorly, and teres major inferiorly. 

The triangular space contains the scapular circumflex artery, and is bordered by the long head of the triceps laterally, teres minur superiorly, and teres major inferiorly. Finally, the triangular interval contains the radial nerve and profunda brachii artery, and is bordered by the long head of the triceps medially, lateral head of the triceps or humerus laterally, and teres major superiorly.

 

Author : Firas Arnaout

 

42. 21-year-old infantryman dislocates his shoulder during basic training. He is able to make it through training but continues to experience recurrent dislocations. 

A CT demonstrates anterior glenoid bone loss and your sports colleagues indicate him for a Latarjet procedure. The procedure successfully restores stability to his shoulder, but the patient is referred to your office just over 3 months later because he has persistent difficulty with abduction when the arm is internally rotated. 

You suspect an iatrogenic nerve injury sustained during anterior shoulder exposure and offer him a nerve transfer procedure involving the branch of the radial nerve that innervates the medial head of triceps. 

The nerve that is injured in this patient innervates what muscles?

A) Deltoid, teres minor, and supraspinatus
B) Deltoid, teres minor, and teres major
C) Teres minor and teres major
D) Deltoid and teres major
E) Deltoid and teres minor

Correct Answer : E

This patient sustained an axillary nerve injury during a large anterior exposure to the shoulder. The patient is offered a Leechavengvongs radial to axillary nerve transfer, as this will potentially restore the lost axillary nerve function to the deltoid and teres minor. 

The axillary nerve branches off of the posterior cord (along with the radial nerve) of the brachial plexus, travels just inferior to the subscapularis, then winds posterior and travels through the quadrangular space with the posterior circumflex humeral artery. 

The anterior branch innervates the anterior half of the deltoid, while the posterior branch innervates the posterior portion of the deltoid and the teres minor. 

This posterior branch also supplies the lateral cutaneous nerve of the arm. Axillary nerve injury is an uncommon but potentially debilitating complication of shoulder surgery. 

Physical exam would be significant for partial or complete deltoid paralysis, which would be most evident with tested shoulder abduction while in internal rotation. In internal rotation, the supraspinatus is rotated anteriorly and thereby contributes less to abduction. 

The Leechavengvongs procedure involves the transfer of one branch of the radial nerve (to medial, lateral, or long head of the triceps) to the axillary nerve. The goal is to get as much excursion of the radial nerve as possible and transferring the branch as proximally as possible on the axillary nerve

 

Author : Firas Arnaout

 

41. Which Muscle or Muscles would be most affected by this lesion?

A) Deltoid
B) Teres Minor
C) Supraspinatus  
D) Infraspinatus
E) Subscapularis

 

40. The following are all complications of open vs arthroscopic Lateral epicondylitis release except.

A) Lateral collateral ligament injury
B) Posterior interosseous nerve injury
C) Heterotrophic ossification
D) Flexion-extension limitations
E) Revision Surgery

 

39. The following are causes of reverse shoulder arthroplasty failure except:

A) Glenoid loosening
B) Scapula notching
C) Supraspinatus dysfunction
D) Axillary nerve dysfunction
E) Poor Bone stock

 

38. The ulnar paradox relates to :

A) Cubital tunnel syndrome is rarely associated with carpal tunnel syndrome
B) A proximal compression of the nerve leads to a worse deformity
C) After cubital tunnel release the deformity gets worse before it gets better
D)Cubital tunnel syndrome is always bilateral
E) Double pinch syndrome has a far worse outcome

 

37. What is the most common compression site for the posterior interosseous nerve ?

A) The fibrous bands at the start of the radial tunnel
B) Distal border of the supinator
C) The proximal border of the superficial belly of the supinator (the arcade of Frohse)
D) The tendinous margin of the extensor carpi radialis brevis muscle
E) The leash of Henry

 

36. When performing elbow arthroscopy, the arthroscopic portal that must be established first is the:

A) Anteromedial portal
B) Anterolateral portal
C) Lateral portal
D) Posterolateral portal
E) Posterior portal

 

35. Which of the following is the most commonly reported cause of nontraumatic humeral head osteonecrosis?

A) Alcohol abuse
B) Corticosteroid therapy
C) Gaucher’s disease
D) Smoking
E) Hemoglobinopathies

 

34. What is the most common mechanism of anterior dislocation of the sternoclavicular joint?

A) A medially directed force applied to the lateral aspect of the externally rotated shoulder girdle
B) A medially directed force applied to the lateral aspect of the internally rotated shoulder girdle
C) A medially directed force applied to the lateral aspect of the neutrally rotated shoulder girdle
D) An inferiorly directed force applied to the medial aspect of the clavicle
E) A superiorly directed force applied to the medial aspect of the clavicle

 

33. This clinical photograph depicts the examination of a 41-year-old man. 

What is the most likely diagnosis based on this finding ?

A) Anterior shoulder instability
B) Posterior shoulder instability
C) Multidirectional shoulder instability
D) Subscapularis tendon tear
E) Biceps tendon rupture

 

32. A magnetic resonance image of a patient’s right shoulder is shown. The structure marked by the arrows is innervated by which of the following structures:

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

 

31. Which of the following structures is the most important dynamic stabilizer of the elbow to valgus stresses during throwing:

A) Anterior oblique component of the ulnar collateral ligament
B) Posterior oblique component of the ulnar collateral ligament
C) Flexor-pronator musculature
D) Brachialis
E) Biceps brachii

 

30. Which of the following factors is related to recurrence after primary anterior shoulder dislocation:

A) Type of sport practiced
B) Treatment with immobilization
C) Treatment with physical therapy
D) Patient gender
E) Patient age

 

29. Which of the following treatment regimens for shoulder internal impingement in overhead athletes has the highest reported rate for return to preinjury competition level ?

A) Subacromial corticosteroid injections
B) Nonsteroidal anti-inflammatory medications
C) Arthroscopic debridement or repair of associated lesions
D) Arthroscopic debridement or repair of associated lesions with thermal capsulorraphy
E) Humeral derotational osteotomy

 

28. Which of the following is the most commonly reported cause of nontraumatic humeral head osteonecrosis?

A) Alcohol abuse
B) Corticosteroid therapy
C) Gaucher’s disease
D) Smoking
E) Hemoglobinopathies

 

27. A 56-year-old competitive triathelete fell off his bicycle and sustained a traumatic anterior shoulder dislocation. The dislocation was reduced in the emergency room. No associated fractures were noted. 

A magnetic resonance image examination would be judicious in this patient to:

A) Assess the capsuloligamentous integrity of the shoulder
B) Assess for glenoid labrum tears
C) Assess the integrity of the articular cartilage
D) Assess the integrity of the rotator cuff
E) Evaluate the bone for occult fractures

 

26. Which of the following describes the correct relationship between the suprascapular nerve and the suprascapular vessels as they pass through the suprascapular notch:

A) The suprascapular nerve, artery, and vein all pass below the transverse scapular ligament.
B) The suprascapular nerve, artery, and vein all pass superficially to the transverse scapular ligament.
C) The suprascapular nerve passes superficially to the transverse scapular ligament while the artery & vein pass deep to it.
D) The suprascapular nerve and artery pass deep to the transverse scapular ligament while the suprascapular vein passes superficially to it.
E) The suprascapular nerve passes deep to the transverse scapular ligament while the suprascapular artery and vein pass above it.

 

25. Anteroposterior displacement of the acromion on the clavicle is most strongly resisted by which of the following structures:

A) The conoid ligament
B) The acromioclavicular ligaments
C) The osseous articulation of the acromion on the clavicle
D) The acromioclavicular meniscus
E) The trapezoid ligament

 

24. Osteochondritis dissecans of the elbow most commonly occurs at this location:

A) Trochlea
B) Olecranon
C) Capitellum
D) Radial head
E) Coronoid

 

23. The following structure is most responsible for resisting inferior translation of the glenohumeral joint with the arm at the side:

A) Inferior glenohumeral ligament
B) Middle glenohumeral ligament
C) Coracoacromial ligament
D) Coracohumeral ligament
E) Subscapularis muscle and tendon

 

22. The primary restraint to anterior translation of the abducted and externally rotated glenohumeral joint is the:

A) Coracohumeral ligament
B) Superior glenohumeral ligament
C) Middle glenohumeral ligament
D) Inferior glenohumeral ligament
E) Subscapularis muscle

 

21. When comparing open distal clavicle resection with arthroscopic distal clavicle resection for osteolysis of the distal clavicle, arthroscopic techniques:

A) Less reliably resect the appropriate amount ofndistal clavicle
B) Less reliably provide pain relief
C) Have a higher complication rate
D) Require a longer hospital stay
E) Allow quicker return to activity

 

20. This slide is a computed tomogram of the dominant shoulder of a 45-year-old male tennis player. 

The most likely diagnosis is:

A) Osteosarcoma
B) Synovial osteochondromatosis
C) Anterior glenoid fracture
D) Synovial cell sarcoma
E) Rotator cuff tear arthropathy

 

19. This is the radiograph of a right hand dominant 15-year-old baseball player who felt a pop when swinging a bat. Recommended treatment should consist of:

A) Immobilization in a shoulder spica cast
B) Immobilization in a sling
C) Open reduction internal fixation with bone graft
D) Open biopsy
E) Observation

 

18. In a pitcher with an ulnar collateral ligament injury of his dominant elbow, pain is generally most severe during:

A) Wind-up
B) Early cocking
C) Late cocking
D) Follow-through
E) Rest following activity

 

17. What percentage of patients with recurrent anterior shoulder instability has an identifiable abnormality on plain radiography:

A) 10%
B) 25%
C) 75%
D) 85%
E) 95%

 

16. Which of the following is not considered a mechanism of injury for a superior labrum anterior and posterior (SLAP) tear:

A) Traction injury from carrying, dropping, or lifting a heavy object
B) Compression force from a fall on an outstretched arm
C) Repetitive overhead throwing
D) Forceful biceps contraction with throwing a ball or spiking a volleyball
E) External rotation movement with returning a backhand in tennis

 

15. A magnetic resonance image of a patient’s right shoulder is shown. 

The structure marked by the asterisk is innervated by which of the following structures:

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

 

14. A magnetic resonance image of a patient’s right shoulder is shown. 

Identify the structure marked by the arrows.

A) Subscapularis tendon
B) Supraspinatus tendon
C) Long head of the biceps tendon
D) Short head of the biceps tendon
E) Coracohumeral ligament

 

13. All of the following muscles act in scapular retraction except:

A) Trapezius
B) Rhomboideus major
C) Rhomboideus minor
D) Levator scapulae
E) Pectoralis minor

 

12. When assessing patient outcomes after rotator cuff repair, which of the following is not related to poor functional outcome:

A) Workman’s compensation
B) Revision rotator cuff repair
C) Male gender
D) Age older than 55 years at the time of repair
E) Age younger than 55 years at the time of repair

 

11. To avoid injury associated with repetitive internal impingement, the pitcher’s long humeral axis must be in which
position during the late cocking phase of throwing:

A) 20° extended relative to the plane of the scapula
B) 10° extended relative to the plane of the scapula
C) Parallel to the plane of the scapula
D) 10° flexed relative to the plane of the scapula
E) 20° flexed relative to the plane of the scapula

 

10. Disruption of which of the following ligaments represents the primary lesion in posterolateral rotatory instability of
the elbow:

A) Radial collateral ligament
B) Radial ulnohumeral ligament
C) Annular ligament
D) Accessory radial collateral ligament
E) Ulnohumeral articulation

 

9. A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old  cricket player is presented . He has been unable to play for the past 6 weeks secondary to pain. 

The recommended treatment includes:

A) Physical therapy for triceps strengthening 
B) Physical therapy for pronator strengthening 
C) Ulnar nerve transpostion 
D) Radial collateral ligament reconstruction 
E) Ulnar collateral ligament reconstruction 

 

8. A “stinger” (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in contact sports) most commonly affects the:

A) Spinal cord 
B) C-5/C-6 nerve roots 
C) C-7/C-8 nerve roots 
D) Axillary nerve 
E) Musculocutaneous nerve 

 

7.  A 55 -years-old man sustains an open fracture of the radius which was treated with open reduction and internal fixation. This operation was complicated with radial nerve injury which did not improve at follow up. 

Which of the following treatments will best restore function?

A)Transfer of pronator teres to extensor carpi radialis brevis
B)Transfer of deltoid to triceps
C)Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus 
D)Transfer of pectoralis major to biceps
E)Transfer of common flexors tendon to the humerus

 

6.  A 45 years old plasterer complains of long standing pain over the lateral aspect of the elbow. The pain worsens when using a brush. 

On examination, the symptoms are exacerbated with resisted wrist extension while the elbow is fully extended. 

Which muscle is likely to be involved?

A) Anconeus
B) Brachioradialis
C) Extensor carpi radialis brevis
D)Flexor carpi radialis
E) Supinator

 

5.  Which anatomical structure provides the primary dynamic stability and restraint to the shoulder and keeps the humerus head centred on the glenoid?

A) Glenohumeral ligaments
B) Deltoid muscle
C) Rotator cuff muscles
D)Biceps muscle tendons
E) Glenoid labrum

 

4. In shoulder examination, which test is used to diagnose subacromial impingement?

A) Obrien test
B) Apprehension test
C) Cross body adduction (scarf) test
D) Speed test
E) Job test

 

3.  The glenohumeral joint relies on static and dynamic stabilizers to remain centred. Which structure is the main dynamic stabilizer of the shoulder joint?

A) The glenoid labrum
B) The capsule
C) The glenohumeral ligaments
D) The negative intraarticular pressure
E) The rotator cuff muscles

 

2.  The anterior interosseous nerve innervate all of the following except:

A) The pronator quadratus
B) The abductor pollicis longus
C) The flexor pollicis longus
D) The radial half of the flexor digitorum profundus                                                                                                                                                  
E) Wriste capsule

 

1. Dynamic muscular stabilizers of the shoulder play an important role in stability. 

Which of the following is the most important dynamic stabilizer?

A) The rotator cuff
B) The labrum
C) The coracobrachialis
D) The latissimus dorsi
E) The biceps brachii

 

5. A magnetic resonance image of a patient’s right shoulder is shown. 

The structure marked by the arrows is innervated by which of the following structures?

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

 

4. This slide is a computed tomogram of the dominant shoulder of a 45-year-old male tennis player. 

The most likely diagnosis is:

A) Osteosarcoma
B) Synovial osteochondromatosis
C) Anterior glenoid fracture
D) Synovial cell sarcoma
E) Rotator cuff tear arthropathy

 

3. This is the radiograph of a right hand dominant 15-year-old baseball player who felt a pop when swinging a bat. 

Recommended treatment should consist of:

A) Immobilization in a shoulder spica cast
B) Immobilization in a sling
C) Open reduction internal fixation with bone graft
D) Open biopsy
E) Observation

 

2. A magnetic resonance image of a patient’s right shoulder is shown. 

The structure marked by the asterisk is innervated by which of the following structures:

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

1. A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old  cricket player is presented . He has been unable to play for the past 6 weeks secondary to pain. 

The recommended treatment includes:

A) Physical therapy for triceps strengthening 
B) Physical therapy for pronator strengthening 
C) Ulnar nerve transpostion 
D) Radial collateral ligament reconstruction 
E) Ulnar collateral ligament reconstruction 

Test your knowledge , learn more and get ready for your orthopaedic exam

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